Pre-Accident Investigations: Better Questions. March 30, NERC Todd Conklin PhD High Reliability and Human Performance

Transcription

1 Pre-Accident Investigations: Better Questions March 30, NERC Todd PhD High Reliability and Human Performance

2 Never take a sleeping pill And a laxative at the same time. In any order

3 Three Case Studies

4 Direct Senior Leadership Quote We drifted to a place where we started asking the Wrong questions.

5 Accidents Compliance Behaviors Policy/Rules Enforcement The Safety Journey So Far Design Human Factors Process Safety Standardized Systems Time Human Fatality Performance Serious Event New Not like Viewothers Not NO near Individual misses Organizational Exist in success issues Understand Identified work

6 Leadership s response to Events MATTERS

7 Asking Leaders to be Better Leaders is not enough We must develop leadership systems to support reliable performance

8 The Role of the Leader is to provide the initial force towards understanding systems - first Not finding people to blame

9 A Great Shift in Operational Learning Traditional Ops Learning Find Blame Fix Engaged Learning Learn Learn Soak Improve Fix Old New

10 Redefinition of Operational Success.

11 An important consequence of the defining safety by operations that go wrong is the lack of importance of operations that go right. If nothing happens nothing is wrong.

12 Safety is not the absence of Accidents. Safety is the presence of Defenses. Capacity.

13 Workers are as safe as they need to be, being Without too safe, in order to be productive.

14 Until They re NOT..

15 Pre-Accident Investigations, Parts of an Event

16 Worker s Don t Cause Failures. Worker s Trigger Latent Conditions That Lie Dormant In Organizations Waiting for This Specific Moment In Time.

17 We desire seductivel y unambiguous information about

18 Shift your thinking from Why to How

19 Clearly Safe to do Work The Gray Area: Uncertain interpretation of Safe work Clearly Not Safe to do Work Workers Discover Safety While Working

20 Clearly Safe to do Work Event Clearly Not Safe to do Work After the Event, Safety is Clear 20

21 Start Of Job Work Execution Improvement Area Essential Safeguards Fatality Prevention Area Hazard Safety Understood: Drift and Accumulation

22 Workers Are Masters of the Blue Line

23 The Change In How We Must Think About Workers.

24 The Change in How We Think about Workers Historical Outsiders not responsible not smart should stay in their place Uninformed Automatons Single issue Shallow knowledge Process Users Error-Proofed New View Insiders Very Responsible Very smart Idea generators Important Informants Creative/Adaptive Problem identifiers Problem fixers Profound process owners Fail Often, Safe, and Fast

25 We must stop seeing workers as problems to be fixed. But, as Solutions to be harnessed.

26 We don t design human error out of our work systems We design human error in to our work systems.

27 Systems must be designed for both error and violation.

28 Systems Fragile: Non-Robust Stable: Non-Robust Resilient: Robust

29 Resilience We can t really remove risk from our work So, we must build risk competency and failure capacity in our work systems and processes.

30 Resilience Model Adapt Plan Learn Absorb Recover Event (in motion) Linkov 2013

31 Defense Capacity Start Of Job Defense Capacity Safety Understood: Defending Resilience

32 Your Organization must be an operation that is resilient enough to fail and recover over and over and over and over and over and over and over and over and over and over and over and over and

33 A Great Shift in Operational Learning Engaged Learning Learn Learn Soak Improve Fix

34 Is the juice worth the squeeze?

35 Leaders Be Fixated on non-recoverable, highconsequence failures Recognize expertise in the organization and include them in learning Make the complex transparent View safety as the presence of safeguards and not the absence of incidents.

36 The Power of Early ID Capacity Identified or Discovered Problem

37 The Power of Early ID Capacity

38 Todd PreAccident Podcast